nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Monday, May 31, 2010

Don't Forget Memorial Day

It's not just about eating hot dogs and playing baseball.


To my Fallen friends,

To my comrades over the years. (especially Peach, Cathy, Bruce, John, Randy, Torch, Joe, June, Leroy),

To my Dad (26th ID, Bronze Star w/ OL),

To my Son (USMC), and my daughter and son-in-law (USAF aviators),

And to all who have served or will serve,

It's been an honor.  Thanks for your dedication and sacrifice.

Doc D
Brigadier General, USAF (ret)

Thoughts On World No Tobacco Day

Today is World No Tobacco Day, and Memorial Day.

I'm struck by the confluence here.  At one time, a soldier's ration included cigarettes and matches.  Most infantrymen smoked in World War II, and if you talked to them about it, a lot would admit that it was calming, reducing anxiety.

If I was living the horror of combat in those days, I probably would have done anything to dampen down the fear and anxiety.

Tobacco is pharmacologically both a stimulant and a relaxant, based primarily on the actions of nicotine.
"At low doses, nicotine potently enhances the actions of norepinephrine and dopamine in the brain, causing a drug effect typical of those of psychostimulants. At higher doses, nicotine enhances the effect of serotonin and opiate activity, producing a calming, pain-killing effect." (Wikipedia, Nicotine)
It's this sequential and overlapping effect of alertness and arousal combined with relaxation and anxiety reduction that accounts for its popularity in combat and other stressful situations.

Given the overwhelming number of harmful side effects, it's still not surprising that on the front lines it would be useful.

Nicotine alone has almost no addictive potential. The presence of other compounds in tobacco, primarily the monoamine oxidase inhibitors, cause a behavioral sensitization that increases addiction potential.

In any case, all of the above is meant to draw attention to just how vulnerable we all are to engaging in unhealthy behavior when the circumstances push us toward it:  combat, peer pressure, etc.

I'm dubious that No Tobacco Days, like the Lights Out Earth Hour, accomplish anything.  It doesn't seem to impact behavior even for the day, or the hour.  And if people really need a yearly reminder about tobacco or wasting energy, then we're all idiots.

On the other hand, a No Tobacco Lifetime might work.

Doc D

Sunday, May 30, 2010

Medical Quote Of The Day - 30 May 10

"Men worry over the great number of diseases, while doctors worry over the scarcity of effective remedies."
--(Quoted in History of Chinese Medicine), Pien Ch'iao [ flourished 255 BC]

A New Disease: Debt-Related Stress Disorder

According to a recent poll, Americans are suffering from stress about debt...duh.

From the USA Today health blog (May 30),
"An Associated Press-GfK poll finds that 46% of those surveyed say they're suffering from debt-related stress, and half of that group described their stress as a "great deal" or "quite a bit." On the other hand, about 53% say they feel little or no stress at all."
So let me put on my sarcasm hat and suggest that we define a new disease:  Debt-Related Stress Disorder (or DRSD--every disease needs an acronym).  There are legions of therapists just waiting for the income opportunity.  Of course, these patients have no extra income to spend on therapy, so the Helping Profession will have take I.O.U.'s.

The notion that this could become a disease is not far-fetched.  Post-Traumatic Stress Disorder, which was originally defined in relation to the horror of experiencing hand-to-hand combat, is now applied to "people who have been sexually harassed on the job, moveiegoers upset by seeing The Exorcist, and motorists involved in minor accidents..." (from One Nation Under Therapy, by Sommers and Satel--recommended reading).

DRSD is less radical than social anxiety disorder--what we used to call shyness.

Debt-Related Stress can then be added as a benefit under health care plans that meet government standards.

That way all 46% in the survey above will qualify for treatment...until they pay off the disease-causing debt...Never.

Doc D

Drug Price Cuts In Greece: 2nd Company Withdraws Products

The Danish company says Greece already owes them $300M for drugs already sold, and can't take a 25% cut.

Both companies who are making these moves have argued that the effect of allowing the price cut would not only force them to operate at a loss, but would also encourage other countries to "pile on."

I wrote yesterday about Novo Nordisk withdrawing it's insulin injector.  Today Leo Pharma has stopped sales to Greece for two of its products:  an anti-blood clotting agent and a psoriasis drug, according to BBC News (May 30).  Whether a solution is in the works or not appears unclear:
"Mr Combinos [director general of the economy ministry] said Greece had been under pressure from the IMF to make severe cuts and he anticipated that a compromise on a price reduction would be reached soon.  The Greek government has promised to repay 5.6bn euros that it owes to medical companies for hospital equipment and drugs.   But the Greek Association of Science and Health Providers has warned that there is little chance of an agreement and that the country's debt-plagued state hospitals face a supply embargo."
Nobody's commenting on whether there will be a domino effect on European drug companies.

Is there anything the US can learn from this?  Government-directed price cuts appear to be the culprit, but you can argue that the drug companies are "blackmailing" a debt-ridden country.

I hope we can avoid this kind of turmoil in the US, but I see no reason why it couldn't occur here.  The governor of Massachusetts has already attempted to cut prices that the health insurers can charge.  Maybe they can suck it up for now, as I posted back on April 8th, but the continuing pressure to drive down costs will eventually reach a threshold beyond which the companies can't go--reserves will be exhausted (reserves they are required by law to maintain).

Stand by for the roller coaster ride as the proverbial irresistible force meets the allegedly unmovable object.
Doc D

Saturday, May 29, 2010

50 Years Of Evolving Medical Care

[We're taking care of grandkids today and tomorrow ("Let go of the cat's tail." "Stop hitting your brother.")  So, fewer posts, temporarily.  They are at an age where every corner and hard surface is a head-magnet.]

This was too funny to pass up.  Thanks to Dr. Sandeep Grewal at Kevin MD

Conversation between a doctor and patient in 1960s:

Patient: Sir, I am having a sore throat for last few days with some cough but no fever.
Doctor: You need to go home, take some rest and don’t forget to drink some nice hot tea.

Conversation between a doctor and patient in 1980s:

Patient: Doc I am a having a sore throat for last few days with some cough and no fever.
Doctor: Why don’t you take this antibiotic for five days. Also don’t forget to rest. And let me check you for strep throat too.

Conversation between a doctor and patient in 1990s:

Patient: Doc I am having a sore throat without fever. I need to know what it is right now. Do I have cancer? Do I have something more horrible than cancer?
Doctor: Well seems to me just a simple infection. But to be on the safe side let us send you to ENT specialist for further check up. By the way the strep test is negative.
Patient: Are you sure there is no cancer? My brother is a malpractice lawyer.
Doctor: Ah well! Let us also get a CT scan on your throat.

Conversation between a doctor and patient in 2000s:

Patient: Doc I am having a sore throat and cough. What can I do to make it go away right now?
Doctor: Let me see. Your strep check is negative. My lawyers want me to send you to an ENT specialist and get a CT scan of your neck. Also some blood work. And I have this big gun antibiotic for pneumonia you can use.
Patient: But will my insurance pay for it? I need something they will pay for.
Doctor: Then why don’t you just go home and take rest and drink some hot tea. I will write in the chart you declined my recommendations due to financial reasons.

Conversation between a doctor and patient in 2010:

Patient: Doctor I have sore throat and fever. I tried everything I was told to on a health forum online. But it is getting worse.
Doctor: You have 462. Your 87880 was negative. My lawyers require me to get 88.38. In fact if 88.38 shows that you have 475 rather than 462 then you will need 42821. You have to remember that your chances of having 475 rather than 462 are quite low. But an undiagnosed 475 can lead to 995.92. That will lead to 99223 and possibly 99291 or 99292.
Patient: I don’t understand but will my insurance pay for it?
Doctor: Well 99212 is covered because 462 is a covered diagnosis. Your 87880 is also covered by 462. 88.38 may not be covered because of medical necessity but my lawyers need it.
Patient: I really don’t understand
Doctor: Don’t worry! Neither do I.

ICD-9 and CPT code key:

99212 Low level Physician Visit
88.38 CT Scan NOS
87880 Strep test
462 Acute Pharyngitis.
475 Quinsy (Peri-tonsillar abscess)
995.92 Severe sepsis
99292 Critical Care attention
99291 Critical Care attention
99223 High level Hospital Admission

Greece Orders 25% Cut In All Drug Prices: Danish Company Says "Not Us"

Danish drug company that sells an insulin injector system tells Greek government to pound sand--they won't market the device in Greece.

According to Novo Nordisk, the 25% cut puts the price below what it costs to produce, so they will not offer the product in Greece.  Lots of outrage, etc....

But it's important to note that this device is just a convenience (why drive a Chevy if the government will pay for a Mercedes?).  There are many ways to administer insulin; from alternative injectors to just drawing up your own dose from a vial using sterile syringes.

People just want what they want when they want it.

And the company said they will provide another of their insulin products free of charge.  My guess is the alternative insulin is much cheaper, so the company doesn't take as much of a loss.

There is a lesson to be learned here.  On the one hand, we don't want drug companies gouging patients with exorbitant charges.  On the other hand, we don't want new products withdrawn from the market if price controls are too draconian.  Historically, price controls don't work; they didn't work back in the 70's in the US (you remember the 70's?  gas lines, double digit inflation, Desert One, Quaaludes, disco, one-night stands?)

 I don't think the answer is ANOTHER government oversight committee to tell drug companies how much they can charge.  If I was running a drug company, I would be less likely to fund new research if I knew that some agency could regulate the marketing of any new product I might find.

So, what do we do? 

As I've argued several times in this blog, the problem is not that the free market system doesn't work It just hasn't been tried.  When a company produces a new drug, and other countries put price controls on it, but not in the US, this leaves the door open for the manufacturer to increase prices in the US to cover the lower cost abroad.

Ironically, this means US patients pay more so that patients in other countries can have the drug.  If you're a philanthropist, the knowledge that when you pay for your medicine you are also paying for somebody else's, too, can make you feel virtuous.  But at the same time it's perpetuating the disparity in costs.

So the solution is to levy price controls worldwide, or actually let the market determine a fair price by prohibiting countries from trying to shift the cost to others.  The latter would work better.

Doc D

Friday, May 28, 2010

Medical Quote Of The Day - 28 May 10

"Men are not going to embrace eugenics. They are going to embrace the first likely, trim-figured girl with limpid eyes and flashing teeth who comes along, in spite of the fact that her germ plasm is probably reeking with hypertension, cancer, haemophilia, colour blindness, hay fever, epilepsy, and amyotrophic lateral sclerosis."

--Logan Clendening, MD [1884 - 1945]

UPDATE On The Vaccine-Autism "Doctor"

Even though he is not licensed to practice medicine, I guess Andrew Wakefield still can be called "doctor" because he has a degree.

According to Quackwatch (May 27),
"In 2004, Wakefield relocated to Austin, Texas, where he helped found Thoughtful House Center for Children, a "nonprofit" clinic that features unsubstantiated treatments for autism. He resigned from there after the panel's GMC report was issued. He does not have a medical license in the United States but oversaw the clinic's research program."
I wonder where he is now.

In separate news, Quackwatch reports on another "autism specialist" facing charges in Texas:
The Texas Medical Board has charged Seshagiri Rao, M.D. with nontherapeutic prescribing, failure to secure informed consent, and fraudulent billing related to his mismanagement of five children with autism or autism spectrum disorder. The complaint states that Rao:

--Used an inappropriate urine test to diagnose nonexistent "heavy metal toxicity."
--Inappropriately treated the patients with chelation therapy
--Pretended to insurance companies that he was treating heavy metal toxicity rather than autism.
Autism  and autism spectrum disorder are examples of several tragic, complex abnormalities in children for which there are very few treatment opportunities.

Families need to be extra critical of unsubstantiated claims for success in these diseases.  While it's understandable that people need hope, the result is usually very high cost, involving fruitless and sometimes harmful "treatments"...the hallmarks of quackery.

Doc D

CORRECTION to UPDATE On Health Care Reform Repeal

Transposed numbers in my report of the survey about repealing health care reform.

Earlier today I made an error.  The actual figures are 63% in favor of repeal, and 32% not in favor of repeal  (I wrote 23 before).


Doc D

UPDATE On Health Care Reform Repeal

Actual repeal seems very unlikely, but I would have said "impossible" two months ago.

Polls show that despite Congress and the Administration's efforts to roll out as much health care goodies as quickly as possible, the consequences, intended and unintended, are driving deeper disapproval ratings.

Current surveys of likely voters shows a widening gap for repeal of the law.  63 % are in favor of repeal, while 23 % are not (Rasmussen). 

The number of states supporting the constitutional challenge has risen to 33 (not all are part of the lawsuit).

Finally, Senators introduced a bill Thursday to repeal the bill altogether, replacing it with one of the six plans that Republicans offered during the debate prior to passage of the current law.

Well...fat chance in a one-party rule situation.  This is a political move that won't be seriously considered.

But clearly, momentum is not with the supporters of the new law.

This is really tragic.

I sure wish we had more people with experience of health care working on it (Obama, Sibelius wouldn't know a patient from a tort), and not political ideologues (some of whom have medical degrees, like the new nominee to head up Medicare).

In case you've forgotten, my view is that the success of our health care system rests on four pillars: coverage, quality, access, and cost. (not in any particular order).  To review my essay on this from August of 2009, go here

The new law is mostly successful on coverage, helpful and harmful in improving quality, does little for access to care, and fails utterly at cost control.

Doc D

Paying for Medical Complications

If I get a surgical infection, shouldn't the hospital or doctor pay the price of my care?

A good idea gone wrong.  In an effort to reduce preventable medical errors the Centers for Medicare and Medicaid Services (CMS) announced in 2007 that
"Medicare and Medicaid would no longer pay for the treatment costs of “conditions that could reasonably have been prevented” in an effort to improve patient safety and rein in health care costs. Instead, hospitals and physicians would have to take responsibility for these errors and cover their own costs."
The original list included things like leaving a surgical instrument inside a patient's abdomen.  As the author of the recent article in the NYT Well Blog (May 27), describes it, the "experts had assembled a list of complications so egregious that they called them “never events,” as in they should never occur."

And no one would argue with the original items on that list--leaving an instrument inside somebody should be a "never event."

This is a policy patients and their advocates think makes sense.  Just like "loser-pays" in legal challenges, the public sees a "doctor-pays" rule for medical complications as justified.

Unfortunately, patients are different.  They can get the best care on the planet and still experience some complications.  The cost-cutting success of the original "never" list led to CMS expanding the list of events for which they won't pay--this time adding items not recommended by the experts.

So the list has expanded beyond the "never" event into a "it happens no matter what" list, denying payment for all.

For example, patients with diabetes, kidney failure and malnutrition from other causes are more likely to develop surgical wound infections than others.  The inclusion of "wound infections" on the "never" list is unreasonable.  On occasion, even people who are otherwise healthy get wound infections; in those cases, there is sometimes a way to go back and say, "if we had done this, the infection might not have happened."  In others no cause can be found--all safety and antisepsis rules and practices were followed.

This converts quality medical care into an arbitrary judgment call.  The arbitrary element in some ways resembles the concerns over comparative effectiveness in the health reform law.  Many are concerned that agencies will make similar arbitrary or cost-cutting decisions where there is no other justification.   Denial of coverage is a standard technique in countries who are concerned to control costs, and there have been many scandals in countries like Great Britain, Canada, New Zealand, and others where these oversight organizations have ruled inappropriately. 

For my personal take on comparative effectiveness see my post here.  For previous posts on this and the scandals in other countries see here and here and here.
Given that the CMS is trying to not pay for complications that WILL occur even with the best medical care, it creates not an incentive to improve, but a disincentive to care for people who are at increased risk of complications.  Most doctors will step up to the plate, but warily...and hospitals will consider them a drain on their solvency.
The result is counter-productive to the original initiative, and I'm pretty sure that's not what Medicare intended.

Doc D

Thursday, May 27, 2010

Medical Mis-Communication: It's A Wonder We All Survive

These are called Medical Malapropisms

"Doctor" jargon frequently undergoes a major tongue-twisting when talking to patients:  unfamiliar terms are transformed into familiar sounds and phrases.  The mature physician will let these slide without reaction.

--These are some I've run across over the years.

junkovitis (conjunctivitus)

teflon pearls (Tessalon perles, for cough)

castor oil (cholesterol)

incompetence (incontinence)

smiling mighty Jesus (spinal meningitis) --I've been told patients say this, so it may be apocryphal...pun intended.

ministration (menstruation)

blood clogs (blood clots)

ammonia (pneumonia)

--Then there are the misplaced consonants: 
vomiking (vomiting) and naugizated (nauseated) and elipepsy (epilepsy)

--And there are the borderline phenomena where the word is right, but the pronunciation is mis-applied.

angina:  pronounced "an-GI-na"  (for "AN-gi-na," accent on the first syllable), possibly by osmotic transfer from "va-GI-na."  I've heard a few people say "VAG-i-na," ...but not in the South.
As I wrote this, I found other websites where doctors and nurses have recorded their experiences of patients' verbalization of medical terms. 

If you think patients are funny, try some of the medical chart entries (Chart Bloopers), where doctors and nurses write stuff on the patient's chart that makes no sense ("the patient is comatose and offers no complaints.")

Doc D

Study On Rheumatoid Arthritis Rising In Women, Causes Unclear

This is an interesting study and a classic for looking beyond the headlines.

Warning:  this is an article for Onion Peelers, who like to peel back the layers of what the media tells us about medical research.

The Mayo Clinic released a summary of their recent work on rheumatoid arthritis (RA).  Here's how the press puts together the results.  From the BBC (May 26):
Rhematoid arthritis 'on the rise in women.' Researchers from the Mayo Clinic in Minnesota say rheumatoid arthritis cases rose 2.5% between 1995 and 2007, after 40 years of decline, but fell among men in the same 12-year period.
No here's how the Mayo Clinic described their results (The Medical News, May 27),  from lead author Dr. Sherine Gabriel:
"We observed a modest increase of RA incidence in women during the study period, which followed a sharp decline in incidence during the previous 4 decades," said Dr. Gabriel. Results show that RA incidence in women increased by 2.5% per year from 1995 to 2007, while a decrease of 0.5% was noted for men. ... The overall age- and sex-adjusted prevalence of RA increased from 0.62% in 1995 to 0.72% in 2005.
First observation:  for those who feel stiff in the morning, "rheumatoid" arthritis is not "degenerative" arthritis, which is what almost all of us have.

Arthritis of the rheumatoid kind is a more serious problem, and one of the auto-immune diseases, where our own bodies begin to attack our this case, our joints.  As you can tell from the above, 62 cases per 10,000 makes it a very uncommon disease.

The decrease in men over 10 years is pretty minimal since a lot fewer men get it in the first place:  RA is more common in women by about a 3 to 1 ratio.  Note that the media tried to make the contrast in rates a more serious phenomenon than it is.

So why would the number of cases increase over the ten year period in women, when it was on the decline before?  The most likely culprits are "external."  That is, (1) environmental changes, (2) behavioral changes, or (3) chronically used drugs.

There's absolutely no data at this point to tell us the answer, but my bet is on hormonal replacement.  Environmental factors like air, food, water, and toxic exposures are all going to be hard to separate out.  Behavioral changes:  well, we know smokers are at higher risk for RA.  But smoking has been declining, more slowly in women than in men, but it's still going down.  That leaves drugs.

By coincidence, this reversal in RA cases began about the time the amount of estrogen in  hormone replacement pills was lowered.  At this point, it's all speculation, but this is where I would put my money if I had to bet.

The lesson we learn every day in medicine (both as patients and as doctors) is treatments are never completely benign, there are always consequences, side effects, and balancing influences to consider.

Doc D

Medical Quote Of The Day - 27 May 10

Sorry:  I published today's quote without typing in the actual quotation.  Dumb 

"Poisons and medicine are oftentimes the same substance given with different intents."
--Peter Mere Latham [1789 - 1875]

We Have Fat Kids Because The Parks Are Too Far Away...Not

A park for every American child.  What a great fitness idea!

A report from the Centers for Disease Control (CDC) says that
"one reason so many American kids are overweight is that few have a nearby place to play and exercise.  Only about one in five homes have parks within a half-mile, and about the same number have a fitness or recreation center within that distance." (Assoc Press, May 25)
Let's stop right there.  As a kid, I played outside 'til dark every day, and I think I went to a park about twice a year.  Most of the time we shot hoops, played baseball, played tag...ALL IN THE FRONT YARD.  My Mom told us to shut off the TV and get outside, be back before dark.

Are our public health officials suggesting that to combat childhood obesity we need to put a park by every kid's house, so they won't have to walk anywhere?
Fair enough if some kids live in high density housing and neighborhoods.  Still, a half-mile is a 10-minute walk (exercise, get it?)
Comes to that, why aren't there exercise programs in the schools?  Not the worthless, do-nothing periods most schools now have.  When I was in elementary school we couldn't wait to get to the playground for recess to play kickball, fox-across-the-river, skip rope, dodge ball, etc.  We RAN outside to play, and RAN back in when recess was over.
Drive by an elementary school today and observe the process.  Kids frequently are forbidden to play "competitive" games where somebody might lose (heaven forbid, they'll be scarred for life), or where children might find themsleves more or less able than others (and be challenged to improve, what a concept). 
Children are not allowed to run on the playground....Say what?  Answer from the schools:  they might hurt themselves....What?  Look, we skinned our knees and all that, it was part of learning motor coordination.  Our Dads would say, "Are you dyin'? No? Then shake it off and go play."
I don't remember seeing teachers on our playground at school, but I'm sure there was one....One.  Today there is a quota, which they all hate, and the job consists of "policing" the kids:  "don't do that", "stop running" etc.
Look around today's playground.  There'll be a few kids throwing a ball around, a few hanging on the swings talking, the rest just laying out.  Nobody's having any fun.
For you older folks, remember President Kennedy's physical fitness challenge?  We had to run, do pull ups, sit ups.  Our progress was recorded in school, and we earned the President's Fitness Award by achieving a high score.
I don't care whether it costs more to have physical training in schools; cut costs elsewhere, hire fewer low-value counselors, and adopt fewer brainless programs our teachers are required to conduct that are based on some PhD candidate's idea of progressive teaching.  Forget these dopey ideas that competition is bad for kids, that they need to be protected from strife and learning how to get along.  They'll manage...and be better for it.
Lest you see this as some old-timer's nostalgia ("I walked 5 miles to school...uphill...both ways") thing, try this:  it's cost-effective to let kids play, and a lot cheaper than hiring thousands of therapists and nutritionists, or federal regulators to enforce food laws.
If we want fit children in this country, forget calorie labeling in restaurants and fast food laws.  Get 'em moving, every day, foster competition and teamwork 
Doc D

Wednesday, May 26, 2010

Medical Quote Of The Day - 26 May 10

A Short History of Medicine

2000 B.C. - “Here, eat this root.”
1000 B.C. - “That root is heathen, say this prayer.”
1850 A.D. - “That prayer is superstition, drink this potion.”
1940 A.D. - “That potion is snake oil, swallow this pill.”
1985 A.D. - “That pill is ineffective, take this antibiotic.”
2000 A.D. - “That antibiotic is artificial. Here, eat this root."
--author unknown

Trusting Women, Your Protection Is At Hand: Testosterone...Maybe.

I'm not sure what to do with this one.  If I had to guess the message is, "look out, trusting women...or take testosterone."

BBC News reports on this study at the University of Utrecht, where the researchers
"asked adult women to rate the trustworthiness of photos of strangers' faces. The hormone testosterone, normally linked to competition and dominance, made the most socially naive women more vigilant. But it had no effect on women naturally less trusting, results show."
The cohort given testosterone was small, 24 women.  So, I'm not sure how reproducible this will turn out to be.

There are many complex, and sometimes unexpected, consequences of normal and abnormal hormone states in humans.

By contrast, another hormone, oxytocin increases trust, they say.  Once again, I'm not sure what to make of all this.  Oxytocin is a brain neurotransmitter that is released in childbirth to promote labor.  It has some other effects, too.  But other research on oxytocin has claimed an impact on various behaviors, including orgasm, social recognition, pair bonding, anxiety, trust, love, and maternal behaviors.

Right now, this is best left in the Nature Note category.  Only time will tell whether it should be transferred to the Psycho-Babble category.

Doc D

Research Papers: A Language Unto Themselves

For your amusement, here are four research articles in the current issue of the journal of the National Academy of Science, biochemistry section.  I haven't got a clue what they're talking about.

But I hope it's really important stuff...

"Substrate specificity of the TIM22 mitochondrial import pathway revealed with small molecule inhibitor of protein translocation"

"X-ray structure and mechanism of RNA polymerase II stalled at an antineoplastic monofunctional platinum-DNA adduct "

"Obligatory role in GTP hydrolysis for the amide carbonyl oxygen of the Mg2+-coordinating Thr of regulatory GTPases "

"Inositol 1,3,4,5,6-pentakisphosphate 2-kinase is a distant IPK member with a singular inositide binding site for axial 2-OH recognition "

Doc D

Update On Ethics Of Fertility Treatment And Multiple Births

Specialty group says "no regulation needed" despite a lot of issues left unresolved.

A short time ago I posted on the ethical issues with fertility treatments that result in high-multiple births where the infants are at risk of complications and death.

A major organization, ASRM (American Society for Reproductive Medicine), has met to consider how to regulate the fertility industry (see here from the LA Times Booster Shots blog, May 25).  Their conclusion:  we don't need no stinking regulations.  We just need to cover these couples with fertility insurance (rarely covered now), and there will be no need to attempt multiple embryo implants to increase the success rate.  On the issues of fertility drugs which might cause multiple births, the decision is to just not use them, always go for implants.

Implants don't always succeed.  Some women require several attempts, and in some cases the treatment is futile--but you'll only know that when you try many times (and you may be left with fertility drugs as the only alternative.)

So, we're talking about a treatment that is expensive--even one time--and very expensive, adding up the multiple attempts needed in some cases.

Do "reproductive rights" include our obligation to pay for couples to be able to have children--when it works?  Note, if we cover fertility treatment in an insurance plan, this will distribute the cost across every participant who pays premiums, with each payer experiencing little change in premium (even though the procedure is expensive).

What do we do with those premium-payers who do not wish to subsidize a couple's desire to have children?  Not having children isn't a disease that "requires" treatment.  Some say child-bearing and child-rearing are essential parts of human well-being.  Others would disagree.  Still others would say, "If it means so much to you, there are many children out there for adoption."

This brings up another wrinkle to the reproductive rights debate:  are we obligated to provide an opportunity for "children" or must it be "blood-related offspring?"  Some would prefer not to have children if they can't be genetic parents.

And what about those situations where embryos are donated because the woman has no viable eggs, or the sperm come from a donor because the man is infertile?  And all the other combinations of donors, genes, and techniques in-between?  Are we morally obligated morally to provide all that?

Is there a line beyond which society has no obligation to provide someone with the child-rearing experience?

And none of the discussion above addresses concerns where, without regulations, doctors or patients could pursue their own desires.  A worst case would be the couple who finds a doctor to give them multiple embryos, intending to have multiple births, despite the risk to the infants.

The ASRM has not solved the problems.  Their "let's all just pay for it" decision provides a neat solution that gets them paid for doing a lot of fertility work, but kicks the can down the road on the complexity of issues involved.

Doc D

Doctors And Health Care Workers On Strike Here And Abroad

Cost increases in health care are a global phenomenon, here and in single-payer systems.

Universal health care, whether government regulated or single-payer, like free-market health care, is vulnerable to rapidly rising cost.

Those experts who castigate US health care and cite figures for how much a US family pays for health care as opposed to other countries fail to point out that in those other countries families get taxed more to provide the "free" care.

Not unexpectedly, countries like Great Britain and Germany, whose health care systems have been lauded by US reformers, are experiencing the same cost problems.  Even with rationing care based on cost, as Great Britain does, the pressures for more money to provide care are rising.

Now the health care workers are starting to feel the pinch.  A strike of workers over contract negotiations at the Univ of Massachusetts is planned--in our pioneer universal coverage state.  Doctors in MA have also issued a warning that increased costs of running a medical practice combined with overrun emergency rooms are threatening access to, and quality of, medical care in the state.

Finally, 15,000 doctors went on strike (Bloomberg Businessweek, May 17) this week in Germany.  This group, who represent about a third of the physicians employed by local governments, are seeking a pay raise.  Patients are being advised to seek care from university hospitals.

Will we see more of these strikes and warnings in the future?  Probably.

The noose is tightening on elements of health care in this country and abroad.  I've said many times in this blog that the underlying problems of health care cost are not addressed by economic efficiency or organizational changes.  Until we decide how much a human life is worth and how much we owe to one another--as philosophical issues--we won't solve health care's problems.

Doc D

Tuesday, May 25, 2010

Medical Quote Of The Day - 25 May 10


"Sometimes when a doctor gets too lazy to work he becomes a politician."

--Memories of Eighty Years, J. Chalmers Da Costa [1863 - 1933]

For The Record: Autism-Vaccine Doctor Loses License

The Medical Council in Great Britain has stricken Wakefield from the register.

Being stricken from the register is British-speak for revoking a medical license.  The Medical Council cited "serious professional misconduct."

Those long-time readers of Nostrums know I've railed against vaccine nay-sayers for years, and in particular those who bought into the false theories of Andrew Wakefield regarding the MMR shot and autism.

The Council's action was based on his conduct, not his research.  But, seperately, his research from 1997 was repudiated by several co-authors in 2004 .  The British Medical Journal (who published it) also repudiated it recently.

And finally, see my recent post on the dramatic rise in measles (one of the M's in MMR) in Great Britain in the last year...about when you would it expect it to, if people were influenced to stop taking the vaccine back in the late 90's.

The bad news?  Wakefield is in the US now.

Doc D

Long-Term Care In ObamaCare, Another Ponzi Program

ObamaCare's perfect "deficit reduction" health insurance plan:  you pay and get nothing...for years.

Part of ObamaCare was a provision that would save $70B by getting people to voluntarily sign up to buy into a long-term care insurance plan for five years--without benefits--then they would begin receiving coverage (and continue paying).  To put it bluntly, you buy the plan, make payments, have a stroke three years later, need long-term care, and you're SOL, because you don't have coverage until the five-year point.

[the program is call the  CLASS Act – an acronym for the Community Living Assistance Services and Supports Act, see here for an analysis]
Such a deal.  As one critic put it, "this is like buying a house and making payments, but you can't move in."

The $70B in "savings" comes from the amounts people pay in for the first five years.  Does that sound like a savings, when the buyer gets nothing, and the costs continue to rise?  I'm not following here...

Long term care is extremely expensive.  a five year jump start on funding is a drop in the bucket, and the program will quickly become a bottomless pit for which there is no solution other than infusion of tons of cash from tax increases.

But it's worse than that.  The $70B in "savings" is already programmed to pay for other parts of ObamaCare, it won't be reserved to fund the long-term care.  Broke from the get-go.

So why was this touted as part of the overall bill's "deficit reduction?"  Remember that the Congressional Budget Office can project out estimates of cost no further than the next 10 years.  With 10 years of people paying into the program, but the first pay-out for coverage beginning after the 5th year, the balance sheet looks great.

This almost deserves double-credit as two Poison Pills in one.

Doc D

Emergency Hysterectomy Is Risky, Getting More So...And? The Rest Of The Story?

Getting to the truth versus stirring the pot:  the contradiction that journalism fails to address.

Another dopey article in the press that just raises a scare, but fails to put things in context or get to the root of what's going on.

The LA Times Booster Shots blog headline sounds reasonable ("Hysterectomy after childbirth carries higher risks").  But the article spreads a wider net to include data on increases in maternal mortality across the US, then talks about attempts to heighten patient safety.

No foundation is offered to link these pieces of information.

1.  The title, which sounds alarming, is just plain common sense.  When hysterectomies are done after childbirth it's usually a dire emergency.  Are you surprised that there are higher risks in a dire emergency?  This is like comparing a fender-bender to a head-on collision.
2.  Maternal mortality is up some places and down other places.  When you lump it all together, the rate IS higher, but the increase is on the order of 1 in 10,000 to 1.5 in 10,000.  Cause for concern yes, but we're still talking "rare."  Two hundred years ago the mortality rate was as high as 1 in 3.  so what do we do?  The article does a journalistic belly flop (#3).
3.  Attempting to link that mortality increase to safety concerns is...well, the best I can call it is "speculative."  Health care is not getting sloppier and worse; more fruitful would be to ask, "what is the state of health of women who are getting pregnant:"  is it poorer nutrition, younger age, less follow-up in pregnancy, more fertility drug mishaps, etc.?  All of these things have an adverse impact on maternal "safety."  None of that is considered in the article, although the preventive medicine community has performed hundreds of studies that show these to be critical.

We are left with the impression that "the system" is exposing women to higher risks, and more and more are dying every day...all very subtly done, without telling an outright falsehood, but without getting to the heart of the problem.

Typical journalism from the industry that is more interested in profits from selling news, than in pursuing its charter of getting to the truth of things...something we desperately need.

Doc D

Monday, May 24, 2010

Medical Quote Of The Day - 24 May 10

"You have a cough? Go home tonight, eat a whole box of Ex-Lax - tomorrow you'll be afraid to cough."

--Pearl Williams [1914 - 1991]

Disfavor Deepens As Obama Pushes Out More Health Care Candy

A you-know-what sandwich with a pretty bow is still the same sandwich.
The Washington Post (May 21)comments blandly that the public still dislikes the health care law when the Administration keeps pouring out the expensive goodies to bribe them into liking it.
"The rollout of the federal health-care overhaul continued Friday with the Obama administration spelling out how small biotech firms can apply for grants and tax credits of up to $5 million each."
The biotech largesse comes in the wake of earlier announcements about "rules governing tax credits for small businesses that insure their workers, financial aid for companies that cover early retirees, and opportunities for young adults to stay on their parents' health plans,"

Despite their efforts, the polls show continuing, and deepening, disapproval:

"Sentiments are stronger among opponents of the law, the poll found. The share of Americans saying they held "very favorable" views of the law fell to about one in seven, from almost one in four in April, the Kaiser Family Foundation reported. The share with "very unfavorable" opinions of the legislation remained at about one in three."
Political writers and commentators have been saying for many weeks that the Obama Administration is attempting to push as much health care "candy" out the door as possible as quickly as possible in an effort to turn around popular disapproval for their signature health care reform legislation.

Doesn't seem to be working.  People know when they're being taken for a ride.

Doc D

Welcome Back, Measles. We Missed You.

It's deja vu all over again.  The cycle of measles recurrence turns full circle.

Measles makes a come-back about every 15 years, because we humans are too stupid to understand that when it disappears it's because WE'RE ALL VACCINATED.

As AP writer Frank Jordans relates in the Miami Herald (May 21)
"But the number of cases has surged over the past year, with large outbreaks reported in 30 African countries - from Mauritania to Zambia and Angola to Ethiopia - and Indonesia, Thailand, Vietnam and Bulgaria.
Even Britain experienced a worsening measles outbreak.  The disease's resurgence in Britain follows a sharp drop in immunization rates in the late 1990s sparked by the publication of a flawed paper linking autism to the combined measles, mumps and rubella vaccine.  Britain has reported 1,000 cases in each of the last two years - more than 10 times the figure a decade ago."
When people start believing in weird things, bad stuff happens. (It's a law of nature, write it down.)

So, condemned to repeat history, we stop getting the shot....and here it comes again (to paraphrase Dolly Parton).

Some time back I posted a graph of the life cycle of a vaccine.  It's so important that I'm re-posting it today.

Quick review:  Cases of measles (red) go down as immunization rates (blue) climb.  As disease disappears, immunization rates fall, and the disease comes back.  In green:  adverse side effects of the vaccine.

The pattern is typical for all diseases with vaccines:  polio did the same thing.   It's worth remembering that measles sometimes is lethal, particularly so in developing countries.

I predict we'll see a rise in vaccination in Britain when the public starts perceiving the threat, then in 15 years you'll see another rise in measles, as humanity trudges along throughout history doing the same old things.

Doc D

Sunday, May 23, 2010

Another Lie About US Health Care Comparing Poorly To Other Countries

It's always puzzled me when the US comes out second-rate in comparisons to health care in other countries.  No more.

[This may become a series.]

As I learn more about how comparisons are made between health care systems around the world, it becomes apparent that advocates have twisted the data in order to paint a false picture of US health care.  In this day and age, nothing is immune from distortion to serve political ends.

I've written before about the longevity issue here: pick your data to include non-health care-related variables and you can put the US rank down at 37th.  Take the irrelevant data out, and we surge to the top. 

Here's another instance.  US health care quality is frequently criticized for higher infant mortality and prematurity rates. 

Here's how the liars come up with that. 

Strategies that make your infant mortality and prematurity rate look better:

1.  Do not attempt to resuscitate an infant born at 25 weeks or less gestation age (Netherlands).
2.  Do not use aggressive techniques to stabilize infants born at 25-26 weeks (Netherlands).
3.  Do not define any infant less than 30 cm in length as a live birth (Switzerland).
4.  Do not define any infant, regardless of spontaneous breathing or movement, under the age of 22 weeks or 500 grams in weight as a live birth (France, Czech Republic, Ireland, Netherlands and Poland)
5.  Require a medical certificate that an infant was born "alive and well" in order to call it a live birth (France).
6.  Have a poor system for recording live births (tens of thousands of records lost), or mothers are sent to another country for childbirth if the case is complex (i.e., possibly fatal) (Canada)
7.  Label any fatality at less than six months, irrespective of the infant's status, as an abortion (Switzerland).
8.  Do not count any premature infant that dies before what would have been the full term birth date as a live birth (Hong Kong).
9.  Do not count any infant that survives for less than 24 hours after birth as a live birth (Hong Kong, Japan).
10.  Omit one or more of the four criteria for live birth established by the World Health Organization (Germany).

I don't have to describe in detail how these strategies would affect a country's fatality rate, do I?

Sloppiness aside, some of these rules are designed to save money:  very low weight and very premature infants often don't make it.  Where money is not saved, it's hard to come up with a reason to deny that a living, breathing being was not a live birth unless you're playing games.

In the US, ALL of the above instances would have been defined as a live birth, and ALL cases where survival is remotely possible would have been pursued...aggressively.

There's an old saying in politics that's very true:  He who controls the definitions, wins. 

I feel guilty that I have not looked into these interest group comparisons until now.  But "Cost" is next on my list.

Let's both take a lesson:  When somebody criticizes US health care, think about what they're pushing and ask for the complete data.  Don't assume because they are a US citizen they are only interested in the truth.

Doc D

The Ethics Of "Presumed Donor" Laws: A Personal Gift Or A Social Obligation

Beefing up the supply of organs for donation by assuming the absence of an objection to doing so implies consent.

Getting donors for patients who need a transplant is difficult.  Long waiting lists for transplants exist because laws are on the books to protect the wishes of the individual.  You have to take positive legal steps to indicate consent.   But most don't, leaving the question in doubt when the individual is unable to respond (coma, life support).  To deal with the donor shortage, some have proposed laws that turn the formula around:  unless you opt-out of being a donor, then it's presumed that you are willing to donate...making you a "presumed donor."   Opting out would have further advantage of not allowing families to override what you would have decided had you been able to.  But some have a problem with presumed donor laws (WSJ Health blog, May 21):
"Critics[of a presumed donor law], meantime, worry that the law would stir up old fears that doctors wouldn’t try as hard to save the life of someone who was presumed to be a potential donor."
This is the kind of stuff that drives me crazy.  We don't allow "presumed consent" status because people are afraid doctors will say, "Gee, I really need that organ, so let's don't try as hard to save this guy."

Fine.  Organ donation is a sacred gift that should never be presumed.  That's a reasonable position to take.  But, has the level of paranoia gotten this bad?

In several hundred resuscitation attempts, I've not known the donor status of a single patient.

I really don't think people understand what it does for your sense of professional satisfaction to save a life in a desperate situation.

Doc D

Sextuplets From Fertility Drug In Critical Condition

Was This Morally Responsible?

The BBC reports (May 21) on a woman who gave birth to six, 14 weeks early.  All are alive, but the first "few days are critical" in determining whether they will survive, according to a hospital spokesperson.  Birth weights ranged from one to slightly under two pounds.

At 26 weeks, weighing 1-2 pounds, the fatality rate is significant.  In some countries a 26 week premature may not receive aggressive treatment (being a risk of wasted resources), depending on the facts of the case (I will post on this issue in the future.)

Just so we're clear, this is not another OctoMom.  The woman did not have multiple embryos implanted.  However, she did take a fertility drug.  These chemical agents are known to increase the risk of high-multiple births.  To complicate the situation, the couple in question had achieved a singleton live birth several years previously with the fertility treatment.

The question then becomes, what risk will we allow potential parents to undertake in order to secure their reproductive "rights?"  As I've written before, the issue of reproductive rights is a modern one; prior to fertility treatment, someone could postulate a potential right, but there was no way to actualize that right, or an obligation on society to provide it.

Some ethicists would argue that society, or the government, has no right to interfere in such a private matter.  This is the laissez faire approach.  Others would say that the high cost in complications and death from allowing fetuses to be exposed to such risk is repulsive; an offense to virtue.  Others approach the situation from the viewpoint of result:  fetuses are not yet persons, but by contrast, the couple who has one, or two, children (already) from the process should be restricted from undergoing the risk again of multiple live births, which will require extensive and expensive medical care (this latter group would put a dollar amount on the value of human life.)

But we don't have to consider issues related to those made for and against abortion:  whether the fetus is a person, or has rights, etc.  In this case, there are live babies whose existence is a consequence of actions taken by the parents, and are subject to high risk of death and disability, predicted upon the gamble of getting one child.  There's something very disdainful of the value of human life in that sequence.

Limits on reproductive rights are necessary to avoid this.  As a start, I'm in favor of restricting couples who have two live children from further fertility treatments, and denying fertility treatments to women who are at high risk of multiple births.  We may need to go further.

I've worked in too many pediatric ICU's.  It only takes watching one of these little one-pounders struggling to stay alive--and failing--to believe we have crossed the line from "rights" to "license."

Doc D

Medical Quote Of The Day - 23 May 10

"When you no longer know what headache, heartache, or stomachache means without cistern punctures, electrocardiograms and six x-ray plates, you are slipping."
--Martin H. Fischer, MD [1879 - 1962]

Bad News Brett: Hole In The Heart

I'm heart broke over Brett's broke heart.

Forget that.  It's either really COLD, or it sounds like the title of a country and western song.  Shouldn't joke about someone's misfortune...even a rich guy's.  From everything I hear he is an admirable human being, fired up about getting well.  This is the kind of patient every doctor loves to have.

On the other hand, Mr. Michaels has received a double whammy.  He just recently had a transient mild stroke, after recovering from a previous major stroke.

And the cause of the second one is not the same as the cause of the first, according to his doctors.
"The good news is that it is operable and treatable and we think we may have diagnosed the problem that caused the transient ischemic attack (TIA) or warning stroke; however we feel it is highly unlikely this is connected to the brain hemorrhage he suffered just a few weeks earlier."
The LA Times Booster Shots gives the story.  The second problem was caused by patent foramen ovale .  Patent meaning "open," foramen meaning "opening," ovale meaning "oval."  That sounds kinda stupid, "oval open opening," but the word patent means a bit more; as in, "affording free passage."  So that makes more sense.  There are a bunch of foramens (or foramina) in the body and most are normal.

This particular foramen is normal in the fetus, because the circulation is tied into the placenta and must bypass the lungs, which the fetus doesn't use until birth.  At birth, a series of chemical interactions close the hole.  But occasionally it doesn't close.  Here's a picture.

As I've written before, we all have a couple of dozen defects from birth, mostly minor--and mostly we never know about them--or we wouldn't be here.  Sometimes, a congenital defect lies in wait.  PFO is not extremely rare, as former Miss Arizona Leann Hendrix can testify.  Whether it becomes a problem in later life is partly related to the size of the hole, which can be a pinhole or much larger.  The larger the hole, the larger clot can get through and travel to the brain. 

Back when I was in school we had to go into the heart and put a patch over the hole.  Nowadays the hole can be closed by inserting a catheter into a blood vessel up to the heart and closing it, which can be done as an outpatient.

Let's hope Mr. Michaels doesn't have to show us any more of his personal store of congenital defects.

Doc D

Should I Shovel Snow, Walk Up 2 Flights Of Stairs, Or Have Sex....Hmmm

Heart attack victims can recover and resume a full menu of activities...including you-know-what.

This is just for chuckle value.  In an article from Associated Press writer Marilynn Marchione, the issue of how much exertion a person can safely undertake after recovering from a heart attack can undertake.

A thumbs-up and best wishes for anybody who has gone through a heart attack, and recovered.  Life is sweet, isn't it?

But apparently many are fearful of physical wit, sexual activity.

The article sensibly tries to show, quoting cardiologists, that it's OK to have an active sex life.  The TV and movie stereotypes of the collapsed, dead weight lying on top of some hapless participant are largely false.  We only imagine this as a paradigm of the end for a heart attack victim because no one ever films the millions of other circumstances that more commonly exist in our final moments.

But I couldn't help laughing when the experts attempted to give practical advice for the inidicators of physical well-being that would allow one to safely be sexually active.

Shoveling snow and walking up two flights of stairs.  OK, but neither of those sound like things I'm really interested in doing.  And I can guarantee you that the choice among the three "opportunities" to demonstrate a healthy pretty clear.

To all you recovered heart attack victims, go for it.  Shovel snow (or whatever) to your heart's content (pun intended.)

Doc D

Saturday, May 22, 2010

Medical Quote Of The Day - 22 May 10

"Health consists of having the same diseases as one's neighbors."
--Quentin Crisp [1908 - 1999]

Obamacare Lite in MA Imposes Price Controls, The Result As Predicted

Economists tell me that price caps never work, but that doesn't stop MA from learning the lesson again.

The Boston Globe reports that the top four insurers in Massachusetts (all non-profit) have lost $116M since the Governor imposed price controls on their health insurance plans in April.

The state's response to the loss was that those plans had plenty of reserves (they are required by law to maintain) to dip into.

So, how long do you think it will take at this rate for the plans to exhaust their reserves covering the losses?

This is like that joke about airline emergencies:  Question: "How far will the airplane takes us on only one engine?"  Answer:  "All the way to the crash site."

At this rate the crash will come, and the companies will be insolvent  (Note once again:  these are NON-profit insurers).

[For those who've bought the Administration's propaganda about evil insurers, go look up the data:  Health Insurance Plans rank 105th in profit margin (4.7%).  The beer and cigarette industry rank 14th and 11th, with profits of 18 and 14 percent. go here.]

For some, the health plan losses will be cause for cheering.  It's what they intended all along, so the government could step in and take over. (As was repeatedly warned before the reform law was passed.)

For others, not the political elite--the patients, the result will be cancellation of their coverage and being thrown into a government-designed set of benefits that may not match what they want for themselves and their families.

Once again (this is getting monotonous) the President's pledge--"you will keep your plan"--is shown to be disingenuous.

Doc D

Eradication Of Smallpox Led To Greater Opportunity For HIV Transmission?

Who'd a thunk it?  I'm thunderstruck at this research...preliminary and speculative though it may be.

Try this one on for size:  Eradication of smallpox, and discontinuing the smallpox vaccine, may have lowered immunity in the population that could have crossed over to inhibit HIV spread in the early years.

You get the picture:  eradicating one horrible, global, lethal disease gave opportunity to another.

Even the most radical environmentalist or New Age, deep-ecology follower wouldn't argue against eliminating a disease that has killed hundreds of millions throughout history, despite their deep aversion to interfering with nature. 

Many of us scoff at the nature lover's fervor about things natural--the inistence that interfering in nature, or introducing major changes into nature, is fraught with danger.

But humanity is arrogant with respect to unintended consequences.  The literature in ecology is full of examples where eliminating one undesirable species allowed another problem species to take its place.

Now we learn of a possible connnection between the eradication of smallpox world-wide and the subsequent withdrawal of the smallpox vaccine MAY have opened a door to the initial growth in HIV infection that led to the AIDS pandemic.

I've reviewed the experimental evidence and if further research continues to substantiate the preliminary findings it should rock the world of preventive medicine.

Here's the story.
1.  It's known that some anti-viral vaccines interfere with the ability of other viral diseases to infect those  vaccinated persons.
2.  The authors of this study noted that co-infection with another viral disease can interfere with HIV.
3.  They took blood cells from test subjects who had received smallpox vaccine (in the military) and from unvaccinated subjects, exposed the cells to HIV.
4.  HIV replication was slowed by about 80% in the cells from those who had received smallpox vaccination.
5.  As smallpox cases fell from the 50's onward, HIV (a background phenomenon) began to accelerate exponentally until breakthrough levells in the 80's--when smallpox was eradicated.

Caution: At this point, linking smallpox eradication to HIV spread is only speculative.  We're seeing confluences, not cause-and-effect...yet.

The LA Times health blog, Booster Shots, blithely mentions the opportunistic consequences of eradicating smallpox, but focuses more attention on the positive aspects of having learned that smallpox vaccine may be used as a foundation for developing an HIV vaccine, something researchers have been desperate to produce for decades.  Lead researcher Raymond S. Weinstein said in a statement,
"Given the great difficulties researchers have encountered in trying to develop an HIV vaccine, the ironic fact is that we may once have had a vaccine that is more effective against the virus than anything that has since been developed, and we threw it away."


I fervently hope this line of work will give us the clue to a safe, effective AIDS vaccine.

BUT, more importantly, the scientific community should never forget that nature is so complex--with millions of variables interwoven--it behooves us to explore more fully even the best intentions in dealing with epidemic disease.

We don't want to pursue eradication if it only lets the next disease in line step up to killing millions more.

Doc D

Friday, May 21, 2010

Medical Quote Of The Day - 21 May 10


"If you want total security, go to prison. There you're fed, clothed, given medical care and so on. The only thing lacking... is freedom."

--Dwight D. Eisenhower [1890 - 1969]

Dopey Article About How Having A "Beer Belly" Leads To Alzheimer's

OK, there's an association between abdominal fat and brain volume...And?

The Stupid Article Award today goes to the BBC for suggesting "Beer Belly Linked to Alzheimer's."

[The authors of the study the BBC is referencing examined waist circumference, Body Mass Index, and other measures of body fat.  They found that as body fat goes up, brain volume (as measured by CT) goes down.]

Like I said:  more abdominal fat, less brain volume--the media misleadingly hinting that the first leads to the second.

But, conversely, it's just as likely that people who have lower brain volume tend to be heavier.  (You remember: which came first, the chicken or the egg?)

And, while there's an association between lower brain volume and dementia, it's just one of a number of such "associations."

Oh...and finally, the subjects of the study were healthy folks, not demented ones.

As usual the media makes no effort to clarify that just because two things have an "association" says nothing about whether one causes the other.

A facetious example:  My pet cat has an automatic feeder.  At about 6PM every day, he stands in front of the feeder, and shortly thereafter the food drops down.  Can we conclude the cat is causing the feeder to give him food?  OR, could it be due to me programming the damned thing for 6 o'clock?
To give the authors credit, they make no claim other than the two things (fat and brain volume) are associated.  Further, they don't claim that lower brain volume is the key to dementia.

Bad on the media for writing an article that sounds like you need to keep thin to avoid Alzheimer's.

You need to maintain a healthy weight for a lot of reasons.  But anybody who obsesses about this study is Scaring Themselves To Death.

Doc D

Congress: We Need To Show Our Ignorance Of Genetics, Schedule A Hearing

Did you know our Congress has a molecular genetics expert?  Yep.

This has to be a joke, right?  Our incompetent Congress is going to hold hearings on the all-in-one genetic test I wrote about last week (here and here).  For those of you who don't follow Nostrums, the test can be bought online, uses saliva that goes to a lab by mail, and gives the donor a report on risk for various diseases which have genetic markers.  The FDA halted its appearance in stores until it can be reviewed.

Apparently Rep Henry Waxman, the Congressman To The Stars (representing Beverly Hills), has scheduled hearings with company officials from Pathway Genomics, who market and process the testing.

[You remember Waxman?  When a number of companies reported a combined loss of well over $1B due to the newly passed health care law--in defiance of the promise that It Will Not Cost More-- he demanded that they appear and explain...until someone took him aside and reminded him that he helped write the law that required them to report these losses.  The hearings were quietly cancelled without explanation.]

[Also, not to cast personal aspersions, but just as a clinical observation from seeing about a half million patients over the years, Waxman's facial and cranial anatomy express the limits that the human genome can achieve in approximating the characteristic facies of Rattus norvegicus.]

Allegedly, Waxman will "want to know details including how the tests are analyzed in a lab, how accurate they are and how the information is handled." according to the Wall Street Journal Health Blog (May 20).

If you want to hear how ignorant your elected officials can appear, I would watch this one.  It's gonna be hilarious.  "Now, this so-called "gene" test you're doing, does it cost money?"  "Yes, Congressman, we're a business."  "Well...uh...what is a gene exactly?"

Waxman probably thinks genes are an article of clothing.

Hey, Wax-baby:  Let people who understand this technology do their job.

For a year and a half this country has been yelling in the ear of Congress and the Administration,  "Jobs!" "Debt!"  and the farce goes on...

Doc D

Thursday, May 20, 2010

Medical Cartoonville



Medical Quote Of The Day - 20 May 10

"A Harvard Medical School study has determined that rectal thermometers are still the best way to tell a baby's temperature. Plus, it really teaches the baby who's boss."

--Tina Fey

Long Overdue Rant About Comparing US Health Care To Other Countries

I'm sick and tired of invidious comparisons of the US health care system to that of other nations.

Yes, we have issues to address. 

But to say that our longevity is ranked 31st among developed nations is false and misleading.  If you correct the multi-national data for deaths from violence and auto accidents--where we rank number one--the US longevity vaults to the top.

Auto accidents and violence are separate, non-health care system-related issues.  You don't fix violence with health care exchanges and abortion funding.  And auto accidents are not causally related to a lack of health insurance.

The same thing applies to other comparisons with the US.  Prices for drugs are much higher, yes.  Because other governments pass laws to not pay as much, and companies make up the difference by charging US patients more.

Here's my proposal:  lets tell all these countries that have benefited from medical innovation and advances that are a result of US entrepreneurship that they can't use the drugs and devices any more--they need to develop their own.  That would take 90% of all medicines, techniques, instruments, devices, and tests off the international market and return them to the country that did the work and invested the capital.

Because none of those other countries contribute squat to developing all the medical treatments that their citizens benefit from.

I once said that to a friend from another country, who was lauding the fact that they received free treatment.  That person was crowing about how it was just a matter of picking up their amoxicillin and bronchodilator from the pharmacy.  I said, "Fine, those were both developed by the US.  We want them back; go develop your own."

And I have a solid, hands-on, examination-room-to-policy-level experience of at least six other countries' health care systems.  They aint that great.  In some cases I've seen patients in those countries that have no idea there are new ways to treat certain illnesses and injuries, they're not covered.  And a lot of people are on waiting lists--they've just gotten used to suffering as being "just the way it is."

Clearly this is farcical, but the US gets no credit for a half-century of health care innovation and progress from which the world benefits without lifting a finger.

And to all those US reformers and activists who love to criticize their own country, go jump in a lake.

[Ah...I feel much better now.]

Doc D

Health Care Reform Employer Tax Credit: Too Little For Too Few

Take away the tax deduction, give a partial tax credit, but only if you're a small company and stay small.

Tax credits are ephemeral, meaning they go "poof" very quickly.  This is why Congress chooses them; it's a way to get buy-in, then they switch it off and resume the tax.  It's like how to boil a frog:  increase the pain so slowly that he never jumps out.

This is what we're seeing here.  The tax credit for small businesses in the health care reform law is targeted to tempt small business, the ones that have the hardest time providing health care insurance.  Once the law takes away the employer health insurance tax deduction, a mechanism is needed to entice them to keep providing it.  Hence the credit.

The first problem is that a bare majority of these businesses provide insurance anyway.  And the tax credit that substitutes for the tax deduction is based on a maximum of 35% of the employer's contribution to employee health insurance, so it may or may not be a break-even deal.

Secondly, the law is targeted to businesses with less than 25 full-time employees whose average income is not more than $50K.  That's just to get in the door.  To qualify for the full credit, the business must be less than 10 employees with under $25K average salaries. 

Only a minority of businesses in the latter employee range offer insurance in the first place.  I don't know the figure, but I'll bet if they are not only under 10, but also under $25K, almost none offer it.   In this recession, I doubt they are going to sign up for an addition expense, partial credit or not.

The businesses with 50-100 employees, who mostly have employee health insurance, get nothing, and lose their tax deduction.  I think many of these companies will wash their hands of insurance altogether...and anecdotally, I've heard they're planning to.

In my view this whole scheme makes no sense, and I don't expect it to keep many employers providing health care for their employees.  [I've lost count of the number of situations that will make hash of the President's promise about "keeping your plan"]

So, IF YOU WORK FOR A SMALL COMPANY, BEWARE:  (1) the incentives in this program are too weak, (2) the program tries to target the businesses least able to shoulder the burden of insurance, and (3) the vehicle of a tax "credit"--which may not be around long--will push employers to dump their program into the exchanges.

Small employers I've talked to are fed up with unreliable and unstable government promises.  They want to focus on sustaining and growing their business, not hiring people to run their employee health insurance program.

And if they ARE successful in growing, as soon as they expand beyond the 25 person threshold, the tax credit goes away.

Punished for business growth...that's a GREAT incentive for economic recovery, eh?

Doc D

Wednesday, May 19, 2010

Doctors Fleeing Medicare In Texas, Fed Up (Pun Intended)

In 2007 a handful of doctors declined to participate in Medicare.  In the last year over 150 have dropped out, 50 in the first 3 months of this year.

An article posted at the Houston Chronicle (May 17), discusses the impact of falling Medicare reimbursement rates and the corrosive effect of over a decade of uncertainty over the method by which Medicare calculates costs.  42 percentage already don't take medicare (62% among primary care docs).

I've written on this topic before.  As predicted, the number of physicians who will accept new Medicare patients, never very high, is falling.  Patients are beginning to have difficulty finding specialists who will accept them.

Further, some patients who have seen the same doctor for many years, will no longer be able to keep their doctor upon turning 65.  Add this to the list of reasons the President's promise "you can keep your doctor" is not true.

Before there are any explosive comments about "rich doctors who only care about money", it's important to know that the government purposely calculates how much it costs to "break even" delivering health care based on the type of care, or type of visit.  THEN, they decide how much to pay for it by taking a percentage off the top.

To understand this better, consider what it takes to run a medical practice.  There is office rental, supplies, employees (nurse, insurance person, and receptionist), malpractice insurance, licensing fees.  Add all that up and divide by the number of patients who get seen and you have an average cost to take care of the average person.

Say that's $80.00.  The government then takes off 10% and pays the doctor $72.00.  Medicare sees this as a way to control costs.  I'm not an economist, but what I would do under these circumstances is obtain reimbursement ABOVE cost from private insurers to break even.  That's one reason why private insurance costs more (there are a bunch of other reasons)

I would do this until the Medicare reimbursement fell below the level where I could make up the difference, then have to stop taking Medicare.  That's what's occurring.

This oversimplifies everything, and the numbers I gave are just examples, not real. (The principles are correct.)  I would try to cut staff, limit inventory of supplies, streamline paperwork (useless:  the paperwork grows faster than you can slim it down) first.

Even though I'm a doctor myself, my wife and I have been told in the last two months by three of our doctors that it's unlikely they will be able to continue to see us (we have government insurance).

Some have suggested that the states make Medicare participation a requirement of licensure as a doctor.  Massachusetts is already exploring this.  But if you want to make access even worse than it's going to be with the upcoming doctor shortage, this is a good way to do it.

When doctors get together they don't complain about wacky patients (well, a little), or money very much.  They are very reluctant to even get involved in financial issues as a rule.  What they complain about is increasing dissatisfaction with the practice of medicine:  the rising threat of litigation (hey, this is America), the increase in useless paperwork, the rising workload as the shortage of doctors grows (such that you can't spend the time you would like with each patient).

Combine the loss of that feeling of accomplishing something professionally with getting squeezed financially, and you'll see a number of doctors retire early or go into other careers.  This year the residencies in this country didn't fill for the first time in memory.  That's a harbinger of things to come.

And the "rich doctor" stuff.  I read somewhere that physicians make, on average, $184,000.00 a year.  In 30 years I never made that much, so I looked into the calculation.  It doesn't included personal professional costs, which can be as high as $50,000.00 on average.  Many specialists make much more, but guess how much the malpractice insurance premium is for an obstetrician in Chicago?  $180,000.00.  I told that to somebody and they said "that amount of coverage sounds low."  I had to say, "No, no, that's the premium."

There's another alternative for doctors who hate all the stuff that has nothing to do with taking care of people, and I've considered it:  get rid of any property that can be taken in a law suit, cancel the malpractice, let your patients know you're not covered, and take only cash. 

However, I would be insulted to be offered a chicken in payment.  A duck, now...

Doc D


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